Healthcare Provider Details

I. General information

NPI: 1770884413
Provider Name (Legal Business Name): E. JACOB M.D, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 E HIGHWAY 98
PANAMA CITY FL
32401-3611
US

IV. Provider business mailing address

629 E HIGHWAY 98
PANAMA CITY FL
32401-3611
US

V. Phone/Fax

Practice location:
  • Phone: 850-914-9119
  • Fax: 850-913-1670
Mailing address:
  • Phone: 850-914-9119
  • Fax: 850-913-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberME0054778
License Number StateFL

VIII. Authorized Official

Name: MRS. SANDY WESTGATE
Title or Position: MANAGER
Credential:
Phone: 850-914-9119